Provider Demographics
NPI:1407846777
Name:LOTT, CHARLES EDMONDSON (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDMONDSON
Last Name:LOTT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602373
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2373
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 LONG SHOALS RD STE 320
Practice Address - Street 2:MISSION FAMILY PRACTICE
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704-8794
Practice Address - Country:US
Practice Address - Phone:828-274-6610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP97973Medicare UPIN
NC2759496AMedicare ID - Type UnspecifiedMEDICARE ID #